STATE OF ENROLLMENT Health Insurance Outreach and Enrollment during COVID-19 By: Mina Schultz, Phelan O'Neill, and Erin Hemlin 2021 The State of Enrollment Report: Health Insurance Outreach and Enrollment during COVID-19 Introduction Signed into law in 2010, the Affordable Care Act (ACA) has succeeded in two of its main objectives: greatly increasing insurance coverage for millions of Americans, and enacting key consumer protections and insurance reforms. From 2010 to 2016, 20 million Americans gained health coverage, decreasing the uninsured rate from nearly 18% in 2010 to 10% by 2016.1 Young adults (18-34) saw especially strong gains. Before the ACA, 30 percent or 1 in 3 young adults lacked health insurance, but by 2018 that rate was cut in half, to just 15 percent. Additionally, key insurance reforms greatly strengthened consumer protections and the quality of insurance: ending discrimination against people with pre-existing conditions, eliminating annual and lifetime caps, requiring plans to cover a minimum set of benefits, and limiting the amount of premiums that could go toward administrative costs and profits, rather than toward health care costs. Lawmakers, aware that extensive outreach and education would be needed to help consumers adapt to the new landscape and take advantage of these new health coverage options, incorporated health coverage enrollment assistance into the ACA, known as the Navigator program. Given the complexities of the new law, higher uninsured rates among young people, and lower rates of health literacy among young adults, opportunity was ripe for a national public education campaign targeting young people, led by young people, in coordination with Navigator programs across the nation. Young Invincibles, founded by young adults motivated by the recognition that young people’s voices were not being heard in the debate over health care reform, set out to provide targeted peer-to-peer education to young adults across the nation. Through a campaign of storytelling, direct outreach, and train-the-trainers to partner networks on outreach best practices, YI helped to educate and enroll hundreds of thousands of young people. In the years since, YI has grown from a small start-up to a national organization with a strong focus on consumer education across health care, higher education, and other key issues of economic opportunity. With the roll out of the health insurance marketplace in 2013, Navigators and certified application counselors (CACs), collectively known as “assisters,” got to work helping consumers navigate the complexities of enrolling in health coverage. Rooted in the communities they serve, assisters offer free, expert help with marketplace applications, plan selection, health insurance literacy education, marketplace appeals, and myriad other issues consumers face when shopping for health coverage. As assisters ramped up their work, many groups faced the same set of extraordinarily difficult and novel problems unique to Open Enrollment and the ACA. However, few opportunities existed for assisters to share their experiences and best practices with each other. During the first Open Enrollment, when assisters were trying to navigate a glitchy HealthCare.gov, broad lack of consumer awareness, and more, having a central place to listen to and share with other assister groups was essential. YI wasn’t the only organization founded to help consumers make sense of the ACA. Enroll America launched its “Get Covered America’’ campaign in 2013 to inform Americans about their new health insurance options. With 1 The State of Enrollment Report: Health Insurance Outreach and Enrollment during COVID-19 YI’s laser focus on young adults and Enroll America’s broader consumer awareness campaign, the Get Covered Coalition was founded in 2014. The coalition offered a unique opportunity to not only help enrollment assisters share these best practices, key messaging, and essential resources, but also to provide a space for national partners and key stakeholders to share regulatory, legal, and other major national updates to the ACA that assisters needed to know about to be most effective in their work. Assisters faced other challenges as well during the early days of the ACA. With no coordinated scheduling system and no directory of where consumers could go to find help, consumers had to overcome substantial confusion and often faced wildly uneven wait times. Assisters at one location might have a hundred people waiting to get help while assisters at another may not see a consumer for hours. Developed by Enroll America in 2014 and managed by Young Invincibles since 2017, the Get Covered Connector (“Connector”) sought to solve this problem. The Connector is a nationwide online scheduling tool that allows consumers to search for free local enrollment assistance. The Connector allows partners to create appointment schedules, track outcomes, and create program reports. Community coalitions such as nonprofits, hospitals, Navigator groups, and federally-qualified health centers are using the Connector for aggregated reporting, outreach, and organizational purposes. More than 600,000 appointments have been scheduled via the Connector. While other scheduling tools exist, the Connector is the only online scheduling tool that was developed and tailored specifically for ACA marketplace enrollment. The State of Enrollment Report has been published three times before by Enroll America, in 2014, 2015, and finally in 2017. Since the last report, the enrollment world has been turned upside down. From a yearlong effort to repeal the ACA through Congress in 2017, to defunding and deregulating by the Trump Administration, and finally a global pandemic, assisters have had to overcome new forms of adversity and develop a brand new set of best practices along the way. As the new Biden administration decides the future of health care reform, the ACA, and the Navigator program, Young Invincibles seeks to elevate the voices closest to the realities of ACA implementation, the successes of assister programs nationwide, as well as the challenges and barriers assisters face in making sure the most vulnerable Americans have access to quality, affordable coverage. Over the first several months of 2021, YI conducted interviews with dozens of people within the enrollment community, representing 13 different programs across 15 different states. Interview participants conduct enrollment assistance directly, provide outreach and education within their communities, and/or provide policy support to assisters. Among these groups were Navigators, health centers, advocacy groups, state agencies, think tanks and other community-based organizations. While nearly all in this community focus on marginalized populations who traditionally face systemic barriers to coverage, we prioritized groups that primarily or solely focus on the hardest to reach populations. We heard from immigrant groups in Michigan, health centers in South Texas, out-of-work performing artists in New York and California, legal aid societies in North Carolina among others, and summarized what we learned from them in the following report. 2 The State of Enrollment Report: Health Insurance Outreach and Enrollment during COVID-19 Background Over the years, assisters have become trusted voices in their communities, offering unbiased, accurate information about not only health insurance, but other community resources, as well as the ACA as a whole. According to a Kaiser Family Foundation report, 94% of consumers who worked with an assister said the experience was helpful, and nearly half reported they would not have gotten covered if not for this assistance.2 The first Open Enrollment period for assisters began in October 2013 with the roll out of the new health insurance marketplace, leading up to full implementation of the ACA on January 1, 2014. The initial rollout was severely hindered by website glitches, crashes, and other issues that kept millions of consumers from successfully enrolling during their appointments. Months passed as government contractors worked to fix HealthCare.gov. Meanwhile, assisters scrambled to find solutions in the face of frustrated consumers. Once the website was finally back up and running, pent up demand meant assisters were inundated with consumers looking to sign up for insurance. Overall, assisters spent the first Open Enrollment Period learning to fly the plane while building it. However, in the months and years that followed, the outreach and enrollment community found its footing. With adequate funding for their programs, assisters got to work doing outreach in their communities to educate people about this new option for health insurance, as well as to get the word out that they, the assisters, were a brand new local resource for health insurance information. Working in tandem with Centers for Medicare and Medicaid Services (CMS), which ran its own campaign to promote HealthCare.gov, assisters received not only financial support from the federal government, but also marketing materials, trainings, and technical support to aid them in effectively helping consumers. President Obama himself promoted the marketplace, and even attended pre-Open Enrollment organizing calls to give assisters a pep talk before the busiest time of year. But even then, with millions more in funding, many programs were barely getting by. With a focus on staffing, especially during Open Enrollment, money for advertising their services was minimal. Assisters made their own